Types of Health Insurance Plans
Health Maintenance Organizations (HMO)
A type of health insurance plan where you pay a set monthly fee (premium) with little to no deductible in exchange for health services from healthcare providers registered with the organization (in-network providers). These healthcare providers agree to meet a determined quality of care and lower their prices for people insured by the organization. However, HMOs do not cover services from healthcare providers outside their network (out-of-network providers) unless it is considered an emergency. You may be required to select a Primary Care Physician (PCP) within their network who then serves your basic healthcare needs and sometimes required to have that PCP refer you to specialty care within network. You may be required to live in the service area of the HMO to be eligible for coverage.
Preferred Provider Organization (PPO)
An insurance plan that has a network of providers that it prefers you to use (in-network providers) and covers out-of-network providers. However, since this plan is less restrictive than most, you pay a higher monthly premium and usually have a deductible. This plan provides more benefits to cover in-network providers. Also, this plan does not require you to visit a Primary Care Physician for a referral before seeing a specialist.
Exclusive Provider Organization (EPO)
An EPO provides a network of providers that you must use exclusively. Meaning, EPO plans do not cover services from out-of-network providers. You may seek out specialty care, such as psychiatry, within their organization's network without a referral from you Primary Care Physician.
Point-of-Service (POS)
POSs are similar to HMOs, except that under certain circumstances you are allowed to use an out-of-network provider. POS plans may give access to out-of-network providers for a higher fee than in-network providers. Like HMOs, you need a referral from a PCP for all specialty care, whether the provider is in or out-of-network.
Medicaid Managed Care
An arrangement between a state Medicaid agency and Managed Care Organizations (MCOs) to cover all or most Medicaid-covered services for their Medicaid enrollees. Medicaid recipients may be enrolled in a private healthcare plan where the state pays the fixed monthly premium. Most states now offer Medicaid through these programs and the majority of Medicaid beneficiaries are enrolled in managed care. If enrolled in a Medicaid Managed Care plan, it is important for the recipient to know which private insurance company their plan is enrolled in order to contact regarding their benefits.
High-deductible Health Plan / Health Savings Account
In a High-deductible Health Plan (HDHP), you pay a higher deductible than most health plans but pay a lower premium. When you need a healthcare service, you first pay out of pocket, then the insurance company will help you cover the medical costs. Usually people will combine a HDHP with a Health Savings Account (HSA). With an HSA, your pre-tax money that you put in this savings account will contribute to health costs not covered by insurance, such as coinsurance, copays or dental care. For reference, those with employer-based health insurance are eligible to combine HDHP and HSA.
Indemnity Health Insurance Plans
Indemnity plans are known as “fee-for-service” plans. Under an indemnity plan, you are able to see any specialist you like. Usually you will pay an upfront out-of-pocket fee, and then file a claim to be reimbursed for the covered amount by insurance. You are typically responsible for deductibles and coinsurance costs.
Fee for service
A payment model where services are unbundled and paid for separately. Payments are only issued after the service has been provided and are for each separate service (for example: office visits, tests, procedures, or other healthcare services). When using a Preferred Provider Organization (PPO) plan, less money is paid out-of-pocket and typically does not require filing claims or paperwork. When fee for service plans are provided by insurance outside of a PPO, the health plans will either pay the medical provider directly or reimburse you after you have filed claims for each of the covered expenses.
Qualified Small Employer Health Reimbursement Arrangements (QSEHRAs)
A QSEHRA is a health insurance plan designed for small businesses with fewer than 50 employees. A QSEHRA offers employees a monthly allowance of tax free money. Employees then choose and pay for the healthcare services they want, and this includes their individual health insurance policy. Employees file for reimbursement, and the business will reimburse them up to their allowance amount.
If you need more assistance, feel free to reach out to our Support team at support@miresource.com.
A type of health insurance plan where you pay a set monthly fee (premium) with little to no deductible in exchange for health services from healthcare providers registered with the organization (in-network providers). These healthcare providers agree to meet a determined quality of care and lower their prices for people insured by the organization. However, HMOs do not cover services from healthcare providers outside their network (out-of-network providers) unless it is considered an emergency. You may be required to select a Primary Care Physician (PCP) within their network who then serves your basic healthcare needs and sometimes required to have that PCP refer you to specialty care within network. You may be required to live in the service area of the HMO to be eligible for coverage.
Preferred Provider Organization (PPO)
An insurance plan that has a network of providers that it prefers you to use (in-network providers) and covers out-of-network providers. However, since this plan is less restrictive than most, you pay a higher monthly premium and usually have a deductible. This plan provides more benefits to cover in-network providers. Also, this plan does not require you to visit a Primary Care Physician for a referral before seeing a specialist.
Exclusive Provider Organization (EPO)
An EPO provides a network of providers that you must use exclusively. Meaning, EPO plans do not cover services from out-of-network providers. You may seek out specialty care, such as psychiatry, within their organization's network without a referral from you Primary Care Physician.
Point-of-Service (POS)
POSs are similar to HMOs, except that under certain circumstances you are allowed to use an out-of-network provider. POS plans may give access to out-of-network providers for a higher fee than in-network providers. Like HMOs, you need a referral from a PCP for all specialty care, whether the provider is in or out-of-network.
Medicaid Managed Care
An arrangement between a state Medicaid agency and Managed Care Organizations (MCOs) to cover all or most Medicaid-covered services for their Medicaid enrollees. Medicaid recipients may be enrolled in a private healthcare plan where the state pays the fixed monthly premium. Most states now offer Medicaid through these programs and the majority of Medicaid beneficiaries are enrolled in managed care. If enrolled in a Medicaid Managed Care plan, it is important for the recipient to know which private insurance company their plan is enrolled in order to contact regarding their benefits.
High-deductible Health Plan / Health Savings Account
In a High-deductible Health Plan (HDHP), you pay a higher deductible than most health plans but pay a lower premium. When you need a healthcare service, you first pay out of pocket, then the insurance company will help you cover the medical costs. Usually people will combine a HDHP with a Health Savings Account (HSA). With an HSA, your pre-tax money that you put in this savings account will contribute to health costs not covered by insurance, such as coinsurance, copays or dental care. For reference, those with employer-based health insurance are eligible to combine HDHP and HSA.
Indemnity Health Insurance Plans
Indemnity plans are known as “fee-for-service” plans. Under an indemnity plan, you are able to see any specialist you like. Usually you will pay an upfront out-of-pocket fee, and then file a claim to be reimbursed for the covered amount by insurance. You are typically responsible for deductibles and coinsurance costs.
Fee for service
A payment model where services are unbundled and paid for separately. Payments are only issued after the service has been provided and are for each separate service (for example: office visits, tests, procedures, or other healthcare services). When using a Preferred Provider Organization (PPO) plan, less money is paid out-of-pocket and typically does not require filing claims or paperwork. When fee for service plans are provided by insurance outside of a PPO, the health plans will either pay the medical provider directly or reimburse you after you have filed claims for each of the covered expenses.
Qualified Small Employer Health Reimbursement Arrangements (QSEHRAs)
A QSEHRA is a health insurance plan designed for small businesses with fewer than 50 employees. A QSEHRA offers employees a monthly allowance of tax free money. Employees then choose and pay for the healthcare services they want, and this includes their individual health insurance policy. Employees file for reimbursement, and the business will reimburse them up to their allowance amount.
If you need more assistance, feel free to reach out to our Support team at support@miresource.com.
Updated on: 07/11/2023
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